Preparation for Child Psych PRITE and Boards
Revision as of 23:16, 4 February 2013 by Eugene Grudnikoff MD (Talk | contribs) (Introduction)

Jump to: navigation, search

Introduction

Substance use disorders (SUDs) include two major categories: substance abuse (SA) and substance dependence (SD). In addition, there are intoxication and withdrawal states related to specific substances.

The term dependence has two meanings:

  • it may refer to physiological dependence on a substance (e.g. increased tolerance and symptoms of withdrawal),
  • and also to a specific syndrome defined by DSM as follows: "The essential feature of dependence is a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues substance use despite significant substance-related problems."
    • since physiological dependence (tolerance, withdrawal) is expected with many prescribed medications when taken appropriately, DSM-5 will use term addiction instead of the syndrome of dependence. (VERIFY ME!)

Generally, the term illicit substances does not include alcohol, and tobacco, but does include prescription medications used inappropriately. Alcohol, tobacco, and caffeine are "licit" substances in this sense.

While increased tolerance and s/sx of withdrawal are frequently used to screen for SD, they are neither necessary nor sufficient (need 3 of 7 criteria) to make the diagnosis.

Epidemiology

Prevalence of substance use and substance-related disorder increases linearly from early to late adolescence. Approximately one in four older adolescents meets criteria for abuse for at least one substance, and one in five meets criteria for SD.

  • 3% of male seniors reported using anabolic steroids.
  • 1.2% of adolescents report that they used 3,4-methylenedioxymethamphetamine (MDMA) or Ecstasy within the past year.
  • Approximately 2% of U.S. high school seniors reported using gamma hydroxy butyrate, GHB, a CNS depressant, within the past year. (1)
  • "Spice," a synthetic form of THC, is sold as incense in smoke shops and novelty stores. Varying the formula slightly allows manufacturers to continue producing and selling it despite some states' legislation banning the substance.

This table was adopted from a large survey of drug use in adolescents (12-17) in the last year, n=72561 (2):

Substance Population prevalence Prevalence in Native Americans Population fraction developing use disorder Use disorder Prevalence
Alcohol 35% 37% 16% 5.4%
Any drug use* 19% 31% 23.8% 4.6%
Marijuana 14% 23.5% 26% 3.4%
Opioid analgesics 7.5% 9.7% 15% 1.2%
Inhalants 4.5% 5.3% 10% <1%
Stimulants 2.2% 2.4% 17% 0.6%
Cocaine 1.8% 3.7% 23% 0.4%

* excludes alcohol and nicotine.

Few points are notable:

  • Native-American adolescents have startling rates of drug use (not necessarily alcohol); overall, Native-Americans have highest prevalence of substance-related use (47.5%).
  • Opioid analgesics have replaced inhalants as the second most used illicit drug.
  • A quarter of adolescents who use marijuana go on to develop marijuana use disorder; this fraction is higher than for adolescents using alcohol and similar to rates of cocaine and heroin users developing cocaine/heroin use disorder.

Screening

CAGE screen is widely taught and used, however, in adolescents CRAFFT screen is valid and reliable.

C - Have you ever ridden in a CAR driven by someone (including yourself) who was "high" or had been using alcohol or drugs?
R - Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in?
A - Do you ever use alcohol/drugs while you are by yourself, ALONE?
F - Do you ever FORGET things you did while using alcohol or drugs?
F - Do your family or FRIENDS ever tell you that you should cut down on your drinking or drug use?
T - Have you gotten into TROUBLE while you were using alcohol or drugs?

If the CRAFFT score is positive (>=2 "yes" answers), then further assessment is warranted. If an adolescent screens positive for substance use, then the next step is to determine their stage of use and readiness for change, in preparation for doing a brief intervention (BI) using the principles of motivational interviewing (MI).

Treatment

  • For experimentation or regular but not problematic use, providers may offer brief advice about associated risks and introduce the "Contract for Life" that was designed by Students Against Destructive Decisions "to facilitate communication between young people and their parents about potentially destructive decisions related to alcohol, drugs, peer pressure, and behavior" (available at: http://www.saddonline.com/contract.htm).
  • If screening reveals problem use or abuse, then the goal is to provide intervention and counseling.
  • For substance dependence, referral for intensive treatment is warranted. (4)

Opioid dependence

  • Continuing treatment with buprenorphine-naloxone (BUP/NAL) for 12 weeks improved outcome compared with short-term detoxification with BUP/NAL according to a recent RCT (5). BUP/NAL should be tapered before discontinuation.

High-Yield Facts

Black belt facts

  • DSM-IV does not recognize cannabis withdrawal as a distinct diagnosis, despite extensive data that such syndrome exists (3). DSM-5 will include this diagnosis.
  • DSM-IV does not recognize steroids as its own category of abused substances; it's coded as "other substance use disorder."
  • When 3 or more groups of drugs are involved, the condition is coded as polysubstance dependence in DSM-IV. While the term "polysubstance abuse" is used frquently, there is no such diagnostic category in DSM-IV.

Further Reading

(1) Lewis's Child and Adolescent Psychiatry. 2008
(2) Wu et.al. Racial/Ethnic Variations in Substance-Related Disorders Among Adolescents in the United States. Arch Gen Psychiatry. 2011;68(11):1176-1185
(3) Budney AJ, Hughes JR, Moore BA, Vandrey R: Review of the validity and significance of cannabis withdrawal syndrome. Am J Psychiatry 161:1967–77, 2004.
(4) Burke, et. al. Adolescent Substance Use: Brief Interventions by Emergency Care Providers. Pediatric Emergency Care. 21(11):770-776
(5) Woody GE Extended vs short-term buprenorphine-naloxone for treatment of opioid-addicted youth: a randomized trial. JAMA 2008